A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)
A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10
A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities
The Correct Answer is C
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Naloxone is an opioid antagonist used to reverse opioid overdose, including respiratory depression caused by opioids such as hydromorphone.
B: Flumazenil is used to reverse benzodiazepine overdoses, not opioid overdoses.
C: Acetylcysteine is an antidote for acetaminophen overdose.
D: Protamine is used to reverse the effects of heparin, an anticoagulant
Correct Answer is B
Explanation
A. A towel on the floor outside of the shower could be a tripping hazard.
B. This prevents slipping and falls, which is crucial for someone recovering from knee surgery.
C. Slippers with non-slip soles would be a safer choice to prevent falls.
D. While handrails are helpful for mobility and safety, this recommendation does not address the immediate postoperative care needs of the client following knee surgery.
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